Deficient Nurse Call System Functionality
Penalty
Summary
The facility failed to maintain a properly functioning nurse call system on two of its three resident-use floors, as observed during a recertification survey. The nurse call system, which is supposed to allow residents to call for staff assistance from their bedside and bathroom facilities, was found to be malfunctioning. Specifically, the call system lights were not functioning properly, preventing calls from being relayed to staff members or centralized work areas. The manufacturer's specification manual for the Ascom nurse call system outlines that the system should emit tones and illuminate lights to indicate active calls, but these features were not working as intended. During the survey, several instances were observed where residents attempted to use the call system, but the system failed to alert staff. For example, a resident pressed their bedside call button, which resulted in two beeps being heard in the room, but no light was observed outside the room, and no alert was sent to the staff. Certified Nursing Assistants and Registered Nurses confirmed that the system was not functioning correctly, with some call lights not lighting up in the hallway or at the nurses' station. In some cases, call lights needed to be reset multiple times, and staff were unaware of the malfunctions until they were pointed out by the surveyor. The survey also revealed that some call lights were not connected properly, and the system did not indicate when a call cord was disconnected. For instance, a resident was found with their call light cord not attached to the wall, and the system did not show any activation or alert. Staff members, including Registered Nurses, acknowledged the issues and stated that they would inform maintenance to address the problems. However, the persistent malfunctions of the nurse call system indicate a significant deficiency in the facility's ability to ensure residents can effectively communicate their need for assistance.
Plan Of Correction
Plan of Correction: Approved March 17, 2025 1. Immediately inspected and tested all nurse call systems in the facility. All non-functional call lights were replaced, and all nurse call panels were reset. 2. Conducted a facility-wide audit to check the functionality of all nurse's calls in all residents’ rooms. 3. Established a daily check by staff to ensure all call lights are operational. Implemented a preventive maintenance schedule for routine inspections and testing of the nurse call system. Training for nursing and maintenance staff on the importance of the nurse call system and how to report, reset, and escalate malfunctions to the facilities director will begin on 03/10/2025. Training will include video in-service training provided by the nurse call system company for all nursing and maintenance staff. 4. Weekly nurse call audits will be conducted on all units. These results will be presented to the QA committee monthly for three months. The committee will determine the frequency of the audit thereafter. Responsible party: Director of Nursing